Friday, March 25, 2011

Bummer of a day

It's been a down day--I know, I know, I'm on surgery and it's been a down few weeks. Today has really capped off this last month, though.

I'll start backwards first. We have this online system for evaluation of our clinical rotations. Basically, you log a patient, send it to your preceptor for evaluation, and whatever the sum of your evaluations says, that counts for 75% of your grade. The other 25% is your shelf exam.

I got the results of my shelf exams earlier this week. They aren't as good as I had hoped (I can always blame the raging shingles outbreak, I guess), but they aren't so bad that I'll be able to retake them and improve my score. It's basically at or just above the national mean for the disciplines--I'm assuming that is a passing grade for my medical school, but who knows. I had been in contact with my dean, and the understanding was that if I bombed the shelf exams, maybe we'd work out a plan B. Instead, I probably did enough to pass them, but the grades will prevent me from getting honors. I won't know for sure for a few weeks yet.

The other frustrating thing is that the evaluations/grades don't seem to mirror how hard I worked. I got really positive feedback from my family medicine people, and if my shelf exam had been better, I am pretty sure I would've gotten honors. On the other hand, less than half of my pediatric preceptors filled out evaluations. The ones that did maybe put in one or two general comments--nothing bad, but nothing that stands out. I got my rotation assessment, and it really seems bland to me. I got better feedback from neurology! So, despite the fact that all of my pediatric preceptors told me I did a great job, I was comfortable with kids, I should think about pediatrics, etc, it doesn't count for anything if they never responded to the evaluation form.

I still don't have my OB/gyn comments back, but the response rate on those was about 10%. So, 75% of my grade will be based on 10% of my performance. Not fair, but that is how the system works.

I am really frustrated by this. I worked especially hard in pediatrics and family medicine. Now it seems as though all of that work is for nothing. I could've worked much less hard for the same grade. The whole system seems arbitrary, and it is extremely frustrating.

Today has also been a frustrating day on my current rotation. The other med student on my team is a rock star (S, if you read this, you are totally a rock star!). She's great, and I'm glad she's on my team. It's tough for me to be the less preferred member, though. It didn't help today that the resident and I got our signals crossed. I had asked him three times about what he wanted taken care of--when I did it as we had discussed, it was obvious that I hadn't done it the way he wanted. There was no patient harm or anything--I'd never do anything if I was worried it wasn't in the patient's best interest--but it was frustrating. At least the other med student had heard the same thing I did, so I wasn't totally out of my mind. I could tell that the resident was annoyed with me, so I went and finished my to-do list out of his way for a little while.

I was definitely feeling like I could do no right, no matter how hard I tried. I was helping him change a patient's dressing a little later, and the patient looked at me and said, "You're pretty." I nearly cried. I was tired, my hair was back in a messy ponytail, I had no makeup on, and I was feeling down. (And let's not even touch the body image issues I've been battling lately). I looked at him and said, "Thank you. That's the nicest thing anyone has said to me today." Granted, he was on pain meds and probably said that to every person he saw that day, but it made me smile.

I'm just down because today I felt worse than invisible. Despite my best efforts, I feel like all my team sees are my shortcomings. I try hard to write thorough patient histories--I might've caught a colon cancer in a patient and prevented him from bleeding out during surgery--but that gets no notice. I do blood draws, I run scutwork, I do whatever needs to be done and am always willing to take on more. Instead, my low moments end up being the highlights. Today, for instance, even though the resident was busy and I had confirmed the plan multiple times, I should've asked him to show me what he wanted done. I know that doesn't save him any time, but then it would have been absolutely certain that we were on the same wavelength. I thought I was saving him trouble. I didn't want to seem like a pest. Next time, I'll be a pest.

I am glad my three weeks of vascular surgery are over. I really feel like I didn't learn much more than what I could've learned reading a textbook. The service is so busy that there really isn't time for teaching. My overnight call this week consisted of three (very stressful) emergency surgeries with an attending I had never met before. Thank goodness the helpful resident was also on call, as was another med student from the general surgery team. We had an abscess debridement (where the patient lost all of the skin from his anus to his scrotum), an emergency procedure where the patient was bleeding out into his abdomen (and lost most of his blood volume), and another exploratory procedure because the patient was though to have strangulated bowel. There was also a respiratory code on one of our patients on the floor. Thankfully, everything turned out ok, but we were so busy with emergencies (and then the usual night shift work) that there was no time for teaching.

I got to watch surgeries these last three weeks, but I didn't get to do much beyond retract and cut sutures. I did a few blood gas draws and one intubation with the anesthesiologist, but otherwise everything else I learned was from reading. I've been told there is more OR time on general surgery (I'm not sure that is good or bad). I'm not looking to become a surgeon, but I'd like to learn about how surgeons decide what is an appropriate clinical indication, when surgery is worth the risk in some of these high risk cases, how you manage patients post-operatively, etc. I feel like the clinical rotation is supposed to be seeing how the service works. I really feel like I was more of a minion than a member of the team--and questions about why we were doing something were absolutely not encouraged. I understand not answering a general question that can be researched. However, I sometimes had specific questions about why we were doing X in a patient instead of Y. Sometimes the chief resident would give me a one sentence answer, but generally everyone was so busy and overworked that they didn't have time for more than a few words.

Anyway, it was just a rough day. I felt like a piece of crap, and seeing how much the resident preferred my co-medical student was the nail in the coffin. It is absolutely not the other med student's fault--I am thrilled she is on my team--but favoritism hurts. I guess all I can do is try my best. All the hard work I do may never get noticed, but at least I know I am doing it. It's not like my online evaluations will get filled out anyway. Part of me feels like that if there is no chance to get an honors grade on this rotation, why try so hard? My sanity and sleep would probably benefit from me back things down a bit. Still, I feel like I need to do the best I can so that I know my non-honors grade wasn't from a lack of effort on my part.

Here's hoping medicine is a better fit for me...

Saturday, March 19, 2011

Full circle

It's been a crazy few months. I feel completely behind in my life (as well as constantly exhausted), which many people would say is to be expected from long hours/overnight call/weekends during my surgery rotation. However, back in October or so, I was on neurology (which also had long hours), writing my thesis in the evenings, and teaching a chemistry class every other weekend (and grading whenever I had time). And Josh was only 6 mos old then--while he is still not a champion sleeper, he is doing much better now than he was then.

So why do I feel so overwhelmed right now?

I think a lot of it has to do with decisions. Starting in July, I will be a fourth year medical student. Which means I will start applying for a residency position. Which means I better decide what the heck I want to do so I know where I will apply. Which means I need to schedule rotations that will help me figure out what the heck I want to do.

I have friends who are sure they know what they want. Some have known since they entered medical school, some found a field that goes well with their PhD research, and others found a clinical area during their clerkships that they love but had never considered before.

I envy them.

For them, they know what they are doing, so they know how to structure their time in order to get the best letters, when to schedule their Step 2 licensing exam, and when they will have time for electives. There isn't a time crunch.  That is not the case for me. Since my clerkships run until the end of June, I essentially have July and August to figure out what I want to do. Applications begin on Sept. 1.

I had hoped to do an internal medicine AI in July or August, but they were booked, so I ended up with September. The pediatrics AIs are booked until November I think. I have the option to do electives in July or August, but I am not sure what I want to see. I initially figured that I'd end up in adult cardiology, since that is the closest match to my research interests. I'll probably try to get a cardiology elective in July/August if I can. As for what else might be a good choice--I'm stumped. I have to do a month of emergency medicine and a month of geriatrics per our med school requirements, but I might push those until after interview season. I also have to do another AI, and I might try to do a psych one later (more for fun than anything else).

For licensing purposes, after third year requirements are done, I need 7.5 months of clinical time. Two months are my AIs, two months are ER/geriatrics, and I have one month of credit from my clinical tutorial during my PhD. That leaves me a minimum of 2.5 months of electives. I want to do a cardiology elective, and I think a radiology elective might be helpful for me in general. So, I have to find another 2 weeks of clinical work at a minimum. I'm not too worried about that (and if people have suggestions on helpful rotations, I am game).

The last several months have been extra stressful because all of these decisions about the future have been on my mind. I assumed coming into third year I'd do internal medicine. Unfortunately, medicine is my last rotation of third year. What happens if I don't like it? I'm back to square one. There are a few areas that are definitely out--neurology and OB/gyn for sure. Pediatrics has potential in terms of a specialty, but I couldn't do general peds every day, and I have no exposure to specialty pediatrics, so how would I know if that is a good fit? Psychiatry was very interesting, and I am drawn to "thinking" specialties more than "doing" specialties thus far. However, I have no exposure to outpatient psych, there is a lot of overlap with neuro, and I don't want to solely be doing 15 minute med checks--but a lifetime of inpatient psych seems overwhelming as well. 

So far, I have been drawn to areas in which I've received good mentoring. That's why I thought internal medicine was originally a sure thing--I had a wonderful clinical preceptor for three years, and I looked forward to my one afternoon a week in his clinic. I had a great psych attending for a month. I really enjoyed working with all of the pediatric attendings. I felt like all of these people were human--they cared for their patients, they loved their jobs, but they also had families and a life. They treated me like a human and not like a burden.  My question is this: did I like these rotations because I like the material, or did I like them because I felt that my personality seemed to mesh well with the attendings with whom I was working?

Surgery exemplifies that dichotomy for me. Really, the act of surgery doesn't bother me--I don't wake up every morning excited to cut someone open (as some of my residents do), but I also don't dread it. Vascular surgery is pretty boring, but I don't hate it. I drew a blood gas and intubated a patient within the first few days of the rotation, so I'm not put off by procedures. The actual practice of surgery is ok--I could do it, but I don't dream about it.

The culture, however, makes it seem completely out of the question. It is completely hierarchical, misogynistic, and impersonal. People are rude and angry. No one seems to like their job. No one teaches. I would like to say that is unique to my service, but the other two surgery services at the VA seem worse, if that is possible. I haven't heard good things about any of the other hospital services either. These people are great surgeons, but they are miserable human beings. They have no lives outside the hospital, and if they are married/have kids, they rarely get to spend time with their family.

That is not how I want to live my life.

Who knows, maybe if I had been with a crappy attending in psychiatry, I'd never even think twice about it. Maybe if I had worked with an outstanding OB/gyn I'd be more interested in the field. I'm not even going to pretend neurology was an option--let's be realistic :) But really, I'm looking back at my experiences and trying to understand how much of my interest is related to the practice of that field and how much is related to how well I fit into the culture of each rotation.

That has been my stress--what if I choose a field based on a month of experiences in one specific hospital? What if that was an anomaly? How do I separate liking the practice of a certain type of medicine and liking the culture?

If you haven't seen it already, you need to check out this cartoon from the underwear drawer. I try to be open minded about life experiences--that whole "not judging a book by its cover" thing--but as Tim likes to say, sometimes stereotypes are a great timesaver. Also, if you are in the medical field and haven't seen ortho vs. anesthesia on xtranormal, you need to go here. I laughed so hard I almost fell off my chair. Granted, it was during an overnight call and I was slaphappy, but still...

Anyway, I've found many of the stereotypes about the type of person attracted to each field to be generally true. There are exceptions, as there are to anything, but it definitely seems like each field seems to attract its own kind. I'm not sure where I fit. I am enough of a people person to not want something like radiology or pathology that has little to no contact. However, I don't know that I could do something like family medicine that involves one billion outpatient clinic appointments every week. I'd like to do something that mixes longitudinal care outpatient, maybe some inpatient, and maybe some semi-urgent consulting (not like ER, more like a doc saw a patient and is worried about XYZ and called me...)

That takes me back full circle, something like a medical specialty...like cardiology.

I actually was fairly encouraged on Friday afternoon. I was post-call but didn't get to sleep after call Friday because we had mandatory lectures at the medical school. Instead, I left the hospital after rounds, got home about 8:30 AM, drank half a pot of very strong coffee, got some work done at home, and went back to the med school about 11:30. We had a small group session with one of the cardiologists I had never met before. And I LOVED it. Most of the students were zoning out or not interested. You'd think I'd be so exhausted I'd be falling over. Instead, I drank it up. I learned about new criteria for categorizing patient's cardiac risk and how to best interpret test results in ways clinicians don't normally do. I was so interested that I spoke to the doctor afterward about what it would take to work in his clinic (which unfortunately only runs one day a week). It tied together clinical cardiology, bench research, biochemistry/pharmacology, and translational research.

Granted, it is still not a clinical experience with patients, but it was so nice to remember how it felt to be excited about a field of medicine. There is still the chance that I will loathe medicine or cardiology once I am on the wards, but there's a glimmer of hope that maybe my best specialty match is still out there.

I haven't completely ruled out pediatrics or psych, but I feel much better about medicine.

I've rationalized it in several other ways too. First, if I do medicine in residency, I still have tons of specialty options. I could do something with more procedures, like GI, or I could do something more hands-off like infectious disease. I could do academic medicine, private practice, government healthcare, research, or even industry like working for a pharmaceutical company. There are way more jobs for adult specialists than pediatric specialists, so I have more choices in terms of practice environments and geography. Most of all, I can find a specialty with a good fit in terms of the forms of patient care (inpatient, outpatient, etc) that I like.

It feels a bit like a cop-out to say it, but it buys me some time to figure out exactly what subspecialty I want to do. Maybe I'll love medicine during my clerkship and have no doubts that is what I want to do. Maybe I'll hate it, in which case it is time for plan B. Maybe I'll like it equally with psych and pediatrics, and then I'll need to weigh pros/cons. I can't predict how I'll feel after spending clinical time in medicine. I do feel a lot better after yesterday's lecture in terms of the subject material, though. What can I say--I'm a nerd, and I love evidence-based medicine.

So, over the course of the last year, I've come full circle back to cardiology as a potential specialty. I'm hoping that the stereotype of cardiologists (which puts them in a category similar to surgeons) is not true. If it is, I need to decide if I can get through training dealing with that attitude until I can get into a job post-training that is a better fit for what I want. That is still TBD.

I wouldn't call this an official decision of what I want to do, it's a start.

And we still haven't made any of the other important life decisions yet. Still no idea on if/when we want more kids, where we want to live/work, etc. One thing at a time, I guess.

Tuesday, March 15, 2011

MIA

Sorry to be MIA all of February, and March/April isn't looking much better. I have about 6 half-finished posts saved up, so I'll try to get to them as I can. Here's the brief update:

I finished outpatient pediatrics/obgyn/family medicine about two weeks ago.

I also developed shingles about 2.5 weeks ago, right on my left temple (V1 distribution for you medical peeps). It was painful, and it swelled to cover part of my eye--while I was taking shelf exams. I am sure my scores will be awesome. I talked to my dean about it, so we'll see what happens. It's mostly resolved now, though I do have some residual pain. Here's hoping for no post-herpetic neuralgia!

I started surgery last Monday. I HATE IT. I don't mind the procedures or the patients, but the culture is awful. I had the resident tell me yesterday to stop being nice to patients (I took 10 seconds to put the patient's socks back on after we checked pulses). It's a miserable schedule, a miserable rotation, and it will get worse before it gets better. I'm on vascular surgery now, which at least has limited anatomy to be pimped on. I do general surgery in another 1.5 weeks, and that will be awful.

So, I am up at 4, home at 7 (if I am lucky), on call overnight one night/week, and on one weekend day each week. That schedule has absolutely no time to study, since when we are not in surgery we help run the floor. No time to study or read on patients at the hospital means I have to do it at home. I have about an hour with the kids, then I try to accomplish what I can from 8-10, then bed between 10-11 to get up at 4 again. I was on right after daylight savings on Sunday, so it was like 3:15 AM. And did I mention we don't get to be post-call? Because of our lecture schedule, we can take a nap for a few hours, but we aren't allowed to miss any scheduled AM or PM lectures (or AM rounds). That is awesome too.

I absolutely hate surgery, but I only have to last a total of 8 weeks. However, until the end of April, things will probably be sparse. I'll try to update the half-posts I already have, but I can't promise much more than that.

Ugh. Cross your fingers for me!